Got PPE? Richer versus Poorer Hospitals
Consolidated medical groups running multiple hospitals are more resilient to challenges obtaining N95s and other protective gear; money helps explain why.
Without confirming how much PPE it has available, Kaiser called supplies for its hospitals in Fremont, Oakland and San Leandro, “adequate.”
Sutter Health said it’s working to “closely manage” the supply of protective gear for Alta Bates in Berkeley and Alta Bates’ Summit campus in Oakland, including leveraging its multiple locations to shift supplies where they’re most needed.
“Our hospitals are not on their own. They have an entire network backing them up and working to help ensure they have what they need to care for patients now, while continuing to prepare for future surges,” said Monique Binkley Smith, communications manager for Sutter Health. “While we are encouraged by our progress in securing PPE, and our supply is currently adequate to match the current need, our job is far from over.”
But safety-net hospitals keep less cash on hand, because the federal government reimburses them for uninsured patients.
“They're a totally different financial structure and resource structure than the big academic medical centers,” said Plough.
Alameda Health System operates five hospitals; it was spun off from the county more than 20 years ago with the hopes of making its essential health care network more stable. It hasn’t worked that way. Now the system owes the county tens of millions of dollars, and it has had to ask county supervisors for money to keep going.
“I worry that the people who are in charge of this haven't been stellar in performance prior to this, and so it’s hard to have that leap of faith that everything is going to be OK,” said Fagen, the Highland Hospital nurse.
That history is part of why she’s skeptical of current reuse and pandemic protocols, and of using masks that have been resterilized, something that has been discussed but not implemented where she works.
“I feel like that’s going to bite us in the butt later.”
State Tries to Help
In the months since CDPH checked in with hospitals about their needs, California hasn't met Gov. Gavin Newsom’s lofty aspirations for a regular distribution of hundreds of millions of pieces of protective gear. At least not yet.
California’s own data shows that since the beginning of the pandemic, the state has distributed around 50 million N95 and 125 million surgical masks to counties. Earlier this month, Newsom announced the state was finally beginning to receive shipments of N95 masks from BYD, a Chinese manufacturer whose billion-dollar contract had to be extended when it couldn’t get its product federally certified as effective. Other, smaller mask contracts have fallen apart.
Even hospitals that report they’ve been able to keep protective gear flowing say federal and state support in an emergency is essential to the health care system, especially for small medical offices, which never used protective equipment this way before, and for nursing homes, whose needs have changed dramatically.
“The supply chain is not all equal. And our procurement and our ability to procure and further see into the supply chain is not all equal,” said Amanda Chawla, vice president of supply chain for Stanford University. “When you're dealing with a pandemic, you need the ability to support the nation and the community in a different way.”
State and federal stumbles have made the work of county emergency managers who have shored up supplies through local contracts and donations even more important.
The state reports it has distributed nearly 1.3 million N95 masks to Alameda County. By mid-May, the county had distributed about that many masks to health care facilities requesting them. On top of that, the county’s emergency managers have started to build a stockpile of their own.
Alameda County's N95 Guy
In a Dublin warehouse, a team led by Jim Morrissey has amassed a four-month supply of protective gear for Alameda County. That's enough, he said, to support all of the county’s health facilities at current levels of demand.
“I think we have more N95 masks here ... than the state of Massachusetts,” Morrissey said. “We’re in good shape.”
Morrissey is a linchpin with a mouthful of a title: He’s Alameda County Medical Health Operational Area Coordinator, or MHOAC. Every county has one, actually, as part of California’s emergency management system. But they don’t all operate like Morrissey.
Morrissey says he’s been able to fill just about every request from inside the county, distributing more than 15 million pieces of essential supplies in the fight against COVID-19 — everything from masks to shields to gowns to thermometers to hand sanitizer. Word has traveled, he says, forcing him to turn down requests from elsewhere in the Bay Area and Northern California.
“I know other counties, actually, they want to see proof of a back order from a hospital before they will even attempt to fulfill a request,” Morrissey said. “We don't quite go that far. We just say we want you to try.”
What Is a 30-Day Supply, Anyway?
As with every other element of the pandemic response, each county has handled the challenges that health care facilities face in obtaining PPE differently.
Some localities have required hospitals and other facilities to certify they have access to 30 days of PPE as part of the set of “indicators” that guide reopening different types of businesses and activities.
But health care workers and their advocates point out that no common definition of a 30-day supply exists among counties, facilities or even workers, now that hospitals are using "preservation protocols” to economize PPE use during the pandemic, tactics like using isolation gowns in order to conserve more-protective surgical gowns, or disinfecting and reusing N95s.
Sal Rosselli, who heads the National Union of Healthcare Workers, claims that at Santa Rosa Memorial, access to N95s for nurses and other workers in surgery rooms is controlled. St. Joseph Health, which runs the hospital, disputes that. “We never deny a caregiver an N95 respirator in situations that are medically necessary, in fact, we encourage it; it's our policy,” the hospital said.
At Kindred Hospital, says Roselli, health care workers get one N95 a day.
“How do you define that they have a 30-day supply compared to, you know, a hospital that makes them readily available?” Rosselli said. “That 30-day supply definition is different from what we say is a must to be safe.”
Kindred did not respond to a request for comment.
However it’s defined, keeping more supplies at the ready is meant to protect against a surge in hospitalizations — a recurring fear in an often-uncontrolled pandemic.
Dr. Jennifer Tong, the associate chief medical officer at Santa Clara Valley Medical Center, said supply chain disruption might continue as long as there’s a state of emergency declared somewhere in the U.S.
“We expect that we might need to provide this support even if the local disaster has resolved,” she said.
Counties Pick Up the Tab
Shoring up supplies for health care facilities of all shapes and sizes is happening without an entirely clear picture of who will pay for it. At least some of the cost is being borne at the county level at a time when tax revenues, and consequently budgets, are shrinking.
The price of PPE is far from stable; Tong said the cost per unit has increased significantly for most items.
Morrissey of Alameda County says the county has spent at least $13.6 million on stockpiling protective equipment. According to Sgt. Ray Kelly, a public information officer in Alameda County’s Emergency Operation Center, the plan is to try to recoup 75% of expenses from FEMA for that work, as long as it lasts.
“We’re not going to stop buying PPE,” said Kelly. “Do we buy it for the next year, the next two years? Until we get a vaccine? We’re going to have to budget for PPE going into our county budgets for now on.”
Kelly points out that for Alameda and most counties, a new fiscal year begins in just a couple of weeks, and the pandemic has already changed spending priorities.
“We need to at least budget out for the next couple of years for PPE,” Kelly said. “At some point how much of the cost do you put on the taxpayer, where does our responsibility stop, and where do the corporations take over?
Pandemics have occurred before, Kelly says, but nothing like this. He compares COVID-19 to fires, now burning hotter and wilder around the state than they did before a century of mismanagement and changing climate.
Those fires caught many Northern Californians by surprise. Increasingly, counties and their residents are learning to prepare, attempting to minimize the consequences that follow, from a risk more frequent and deadlier than before.
Eventually, Kelly said, everyone’s got to buy their own flashlight.
Will Hospitals Plan Differently?
While Stanford University hospitals sounded concerned about protective equipment in earlier reports to the state, officials report relatively smooth operations for now.
Still, “I do think there will be a change in the industry,” said Stanford's Chawla. At the very least, Chawla suggests that some facilities might change their disaster planning protocols, and move from low-inventory strategies to warehousing supplies.
Emergency supplies from the Strategic National Stockpile kept Alameda Health System hospitals safe during the early peak of the pandemic; more than $60,000 worth of donated gear from a GoFundMe campaign helped supply the emergency room at Highland Hospital specifically.
But nurses and patient advocates say donations and stockpiles are no way to run a health care system.
Essential and safety-net hospitals around the country have been struggling for years, as federal and other reimbursements have dropped.
“It should be alarming, but it's a chronic alarming,” said Plough of the Robert Wood Johnson Foundation.
Nurse Whitten’s voice cracks as she talks about fatigue. In the ER, she says, they sometimes feel “alarm fatigue” — so many bells ringing at the same time, hour after hour, relentless.
She knows the public is feeling this way, too, because of quarantine and COVID-19 fears.
“As tired as you are, think of what it’s like for us,” she said.
Polly Stryker and Laura Klivans contributed additional reporting.
An earlier version of this article misidentified Monique Binkley-Smith's title.